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New York Reproductive WellnessFemale Medical History & Information Please complete this form prior to your meeting with the doctor. Leave blank anything that does not apply to you, that you have questions about or that you wish to speak with the doctor about in private.
Reason for visit (e.g. infertility testing/evaluation, IVF, other)? ________________________________________________________________How long have you had this problem? _________________________________Please discuss the nature and severity of the problem: ____________________________________________________________________________________________________________________________________________________Do you have any personal, ethical, or religious objections to testing or treatments such as inseminations, IVF, egg donor IVF, masturbation to collect a semen sample? Y N If yes, please explain: _________________________________ PROBLEMS CONCEIVING or KEEPING A PREGNANCY? How long have you been having unprotected intercourse (in years/months)? ________________________________________________________________Have any of these tests been done? (please provide medical records, if available; otherwise, testing date and results to the best of your memory)! Hysterosalpingogram or Sonohysterogram/water sonogram: ___________ ___________________________________________________________ Semen analysis: _____________________________________________ Hormone testing (e.g. cycle day 3 FSH/estradiol, AMH, progesterone, thyroid, prolactin levels): _______________________________________ ___________________________________________________________ Laparoscopy: _______________________________________________ Hysteroscopy: _______________________________________________ PCOS Work-Up: _____________________________________________ Pregnancy Loss Work-Up: _____________________________________ Premature Ovarian Failure Work-Up: _____________________________ Ovulation test kits (do they indicate LH surges, and if so, what cycle day do LH surges occur?): ___________________________________________ Please specify # of cycles, the date(s) of treatment, the dosages of medications, and the outcome(s) (i.e. pregnant or not, ectopic pregnancy, or miscarriage).
intrauterine/artificial insemination: _____________________________________Clomiphene citrate (e.g. Clomid or Serophene) with timed intercourse: ________________________________________________________________________Clomiphene citrate with insemination: _________________________________Injectible medications with insemination: _______________________________IVF cycles (also specify #eggs, #embryos transferred, #embryos frozen): _____________________________________________________________________________________________________________________________________Frozen embryo transfers (also specify #embryos transferred): ______________________________________________________________________________Other treatments, or complications experienced (e.g. OHSS, DVT, hospitalization): ___________________________________________________ Examples: autoimmune disorders (e.g. rheumatoid arthritis, SLE, myasthenia gravis), infections (e.g. chicken pox), thyroid disorder, diabetes, asthma, high blood pressure, heart disease, stroke, liver disease/ infection, kidney disease, blood clots (e.g. in leg or lung), bleeding disorder, cancer, and psychiatric disorders (e.g. depression, schizophrenia, bipolar disorder).
1. ___________________ _________________________________________! _________________________________________ 2. ___________________ _________________________________________! _________________________________________ 3. ___________________ _________________________________________! _________________________________________ 4. ___________________ _________________________________________! _________________________________________ Please list all previous operative procedures, including dental work (e.g. dentures and bridges), and if any complications (e.g. anesthesia problems, other): Diagnosis! Doctor/Hospital! Complications 1. ______________________________________________________________ 2. ______________________________________________________________ 3. ______________________________________________________________ 4. ______________________________________________________________ OBSTETRICAL HISTORY (Chronologically, from most recent) 1. Date (month/day/year) of delivery or end of pregnancy: _________________Check which applies: Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Ectopic/tubal pregnancy. If so, left or right? L R Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? ________________Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: ________________________________ Any fertility treatments required? Y N If yes, please specify: _____________________________________________________________________________How long did it take to get pregnant?___________________________________Conceived with current partner? Y N 2. Date (month/day/year) of delivery or end of pregnancy: _________________Check which applies: Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Ectopic/tubal pregnancy. If so, left or right? L R Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? ________________Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: ________________________________Any fertility treatments required? Y N If yes, please specify: _____________________________________________________________________________How long did it take to get pregnant?___________________________________Conceived with current partner? Y N 3. Date (month/day/year) of delivery or end of pregnancy: _________________Check which applies: Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Ectopic/tubal pregnancy. If so, left or right? L R Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? ________________Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: ________________________________Any fertility treatments required? Y N If yes, please specify: _____________________________________________________________________________How long did it take to get pregnant?___________________________________Conceived with current partner? Y N 4. Date (month/day/year) of delivery or end of pregnancy: _________________Check which applies: Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Ectopic/tubal pregnancy. If so, left or right? L R Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? ________________Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: ________________________________Any fertility treatments required? Y N If yes, please specify: _____________________________________________________________________________How long did it take to get pregnant?___________________________________Conceived with current partner? Y N 5. Date (month/day/year) of delivery or end of pregnancy: _________________Check which applies: Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Vaginal delivery or C-section (circle). If C-section, why? _________ Weight of baby (lbs and oz): _____________! Ectopic/tubal pregnancy. If so, left or right? L R Treatment (please circle): methotrexate/ tube removed/ tube opened Elective termination (abortion) Miscarriage less than 20 weeks. If so, was a D&C needed? Y N Pregnancy ended or delivery occurred at how many weeks? ________________Any complications during pregnancy (e.g. stillbirth, high blood pressure, preeclampsia, diabetes, etc.) or after delivery (e.g. heavy vaginal bleeding, retained placenta, etc.)? Y N Specify: ________________________________Any fertility treatments required? Y N If yes, please specify: _____________________________________________________________________________How long did it take to get pregnant?___________________________________Conceived with current partner? Y N (Please provide additional pregnancy information on a separate piece of paper.) When was the first day of your last period? _____________________________ Age when you had your first period: ___________________________________The number of days between the start of one period to the start of the next period? _________________________________________________________How many days of bleeding do you have? ______________________________Do you have painful periods, no periods, heavy or light periods, or bleeding or spotting between periods? Y N Please explain: ________________________Do you need medication (e.g. Provera) to bring on periods? Y N If yes, which medications? _____________________________________________________Age when you first noticed: breast development ______; pubic hair _________;underarm hair ________ Do you have a history of any of the following? Please specify treatment (e.g. I.V. antibiotics, hospitalization, other). Y N ! infection in the fallopian tubes and uterus (i.e. pelvic inflammatory disease) ! ___________________________________________________________ Y N! Chlamydia or gonorrhea infection; or, other STD/ sexually transmitted ! disease (e.g. syphilis, HIV) _____________________________________ Y N! Any other infection (e.g. tuberculosis)? ____________________________! ___________________________________________________________ Which form of birth control have been used [oral contraceptives/ birth control pills, foam or jelly, injectable contraception (e.g. Depo-Provera), diaphragm, progestin IUD, contraceptive patch, vaginal ring, withdrawal or rhythm method]? Y N If so, which one(s), when and for how long? ________________________________________________________________Have you had you fallopian tubes tied? Y N! (if known) and indicate whether you have had a tubal reversal? _____________ When was you last Pap smear? ______________________________________Have you ever had any abnormal Pap smears? Y N If yes, did you need colposcopy, LEEP or a cone biopsy? __________________Any history of breast masses or nipple discharge? Y N If yes, what kind of evaluation or treatment did you receive? _______________________________Last mammogram, breast ultrasound or breast examination: ________________ Please list all the medications or substances that you have an allergy to (e.g. latex, antibiotics, foods, environmental agents), and the reaction experienced (e.g. rash, hives, throat closure, anaphylaxis).
1. ______________________________________________________________ 2. ______________________________________________________________ 3. ______________________________________________________________ 4. ______________________________________________________________ MEDICATIONS (including herbals, vitamins, health food store supplements) 1. ______________________________________________________________ 2. ______________________________________________________________ 3. ______________________________________________________________ 4. ______________________________________________________________ How many cups of coffee, tea or caffeinated soda do you drink? _____________Do you or have you ever smoked cigarettes (or used any tobacco product)? Y N If yes, how many packs/day and for how many years? ____________________Do you drink alcoholic drinks? Y N ! ! liquor), how many glasses per day? ___________________________________Do you, or have you ever used other drugs (e.g. marijuana, cocaine, or any other recreational drugs)? Y N Please specify: ___________________________________________________ If yes, what kind and how often? _____________ Current occupation: ________________________________________________Are you aware of any potentially hazardous environmental exposure at work or home? Y N ! Please specify: ____________________________________ What is your ethnic background (e.g. Ashkenazi Jewish, Cajun/French Canadian, Italian or other Mediterranean, African American)? ________________________________________________________________ Do you have a family history of:Y N! breast cancer? If yes, which family members? ____________________Y N! ovarian cancer? If yes, which family members? ___________________ Do you have a family or extended family members (include mother, father, sisters, brothers, children, paternal grandparents/ uncles/ aunts, maternal grandparents/ uncles/ aunts) with any of the following? thyroid disorder, diabetes, asthma, high blood pressure, heart disease, stroke, liver disease/ infection, kidney disease, blood clots (e.g. in leg or lung), bleeding disorder, cancers (e.g. colon) and psychiatric disorders (e.g. depression, schizophrenia, bipolar disorder)? Do you have any family history of any of the following?:Y N! inherited conditions [e.g. Cystic Fibrosis, Muscular Dystrophy, Sickle Cell Anemia, Thalassemia, Huntingtonʼs disease, Ashkenazi Jewish diseases (e.g. Tay-Sachs, Gaucher disease, Canavan Disease, Bloom Syndrome, Niemann-Pick disease, Fanconi Anemia, Familial Dysautonomia), Fragile X Syndrome, Spinal Muscular Atrophy, Hemophilia, Hemochromatosis, Dwarfism, Polycystic kidney disease, Marfan Syndrome, Galactosemia, color blindness, deafness/blindness)Y N! Down Syndrome, or other chromosomal defectsY N! autismY N! mental retardationY N developmental delayY N! birth malformationsY N! endometriosisY N infertilityY N! menopause before age 40 Please specify: _________________________________________________ Do you have any of the following? Please elaborate: Y N! acne ______________________________________________________Y N! anxiety, stress or depression ___________________________________Y N! bladder or kidney problems _____________________________________Y N! blood in urine or stool _________________________________________Y N! breast discharge, lumps or pain _________________________________ Y N! breathing difficulty ____________________________________________Y N chest pain __________________________________________________Y N! cough _____________________________________________________Y N! constipation _________________________________________________Y N! diarrhea ____________________________________________________Y N! easy bruising tendency ________________________________________Y N! excessive hair growth _________________________________________Y N! fainting tendency _____________________________________________Y N! headaches _________________________________________________Y N! increased frequency of urination _________________________________Y N increased weakness __________________________________________Y N! irregular heart beat ___________________________________________Y N! leg or arm swelling, pain or redness ______________________________Y N! nausea or vomiting ___________________________________________Y N! pain in abdomen, pelvis or elsewhere _____________________________Y N recent weight gain or loss ______________________________________Y N! skin discoloration or lesions ____________________________________Y N vaginal discharge ____________________________________________Y N vision, smelling or hearing difficulties _____________________________ I confirm that I have read this form and that the information provided by me is true to the best of my knowledge.
Patient Signature: __________________! Date: __________________!

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